CARE RECIPIENT WAIVER
REVIEW AND ACKNOWLEDGE
This waiver should only be signed after you have been referred for care and CDAIDE has requested you complete it.
Our support may include financial aid for urgent needs, access to health care, connection to community resources, mentoring, counseling, and other measures to meet individual needs. All of our services are offered with no strings attached.
CDAIDE takes your privacy seriously and wants to inform you about the protection of your personal information. All volunteers and board members have signed a confidentiality statement and understand that protecting your privacy is essential.
I hereby give permission to CDAIDE to share my circumstances and personal details (including any identifying information I provide) with CDAIDE board members, relevant volunteers, and Care Partners (such as physicians, counselors, etc.) that might assist with my needs. This may involve referral and sharing of personal information to other organizations that I agree to. Data on CDAIDE’s assistance and my personal information will also be stored in CDAIDE’s database and in the database Charity Check, which allows local agencies to collaborate. No identifying details about my story, situation or personal information will be shared publicly without an optional Media Release signed by me, if I wish to share my story more broadly to assist others.